Provider Demographics
NPI:1215549589
Name:FERNANDEZ, NICOLAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 LEACH HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:CT
Mailing Address - Zip Code:06784-2300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-1901
Practice Address - Country:US
Practice Address - Phone:212-547-8861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY024934103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical